New or Returning Member

Name

Spouse Name

E-mail Address

Phone #

Special skills you can contribute to the club (construction, music,painting, landscaping)

What is the #1 item or improvement you would like for the Swim Club to have?

Name as it will appear on Club Roster...E.g., The Brown Family; Bob & Betty Brown; Bob Brown & Betty Brown

Address

Family Members (1)

Family Members (2)

Family Members (3) If child please add age

Family Members (4) If child please add age

Family Members (5) If child please add age

Family Members (6) If child please add age

Doctor's Name (In Case of Emergency)

Doctor's Phone #

Allergies of Family Members

New Member Fee $250.00

Annual Dues $525.00

Work Party Deposit $100.00

$50.00 Late Fee (if paid after 4/14/2011)

Senior Fee $275.00

Inactive Fee $52.50

1st Payment by April 15th

2nd Payment in May

3rd Payment in June

4th Payment by July 15th

TOTAL

How will you be paying?

Please type your KEY ID Name

Member Name Signing or Submitting

Date